Surgical management of pediatric radial neck fractures

Management of pediatric radial neck fractures is controversial regarding acceptable alignment, variable reduction techniques, and suboptimal outcomes. The purpose of this study was to assess the characteristics, management, and results in a surgical cohort, in efforts to identify prognostic factors and offer treatment suggestions. It was hypothesized that less invasive reduction maneuvers would precede open reduction and that worse results would correlate with fracture severity, open reduction, and the presence of associated injuries.

Retrospective analysis of 151 children in whom a radial neck fracture had been surgically treated from 2001 to 2011 was performed. The mean age (and standard deviation) and duration of follow-up were 8.4 ± 2.9 years and 13.3 ± 20.0 months, respectively; 40% of the patients were male. A successful clinical result was defined as elbow flexion of ≥120°, flexion contracture of <20°, forearm rotation of ≥90° with ≥45° of supination and pronation, and no complications.

An isolated radial neck fracture occurred in 54% of the children. The mean angulation and displacement improved from 43° ± 19° and 37% ± 35%, respectively, before treatment to 13° ± 7° and 0.9% ± 4% after treatment (p < 0.001). Twenty-two procedural combinations were used to treat these patients, and 67% of the open reductions were not preceded by percutaneous or closed reduction attempts. Among 131 patients with adequate follow-up, 31% had an unsuccessful outcome. An age of ten years or more (odds ratio [OR] = 5.85, p = 0.001), a time to surgery of two days or less (OR = 4.73, p = 0.02), and greater fracture displacement (OR = 1.25 per 10%, p = 0.001) were independent predictors of unsuccessful outcomes. Increased fracture severity and open reduction were associated with poor results, although the presence of concomitant injuries was not. It is predicted that closed manipulation will fail for half of fractures angulated ≥36°, and that half of fractures displaced ≥65% will require open reduction. The predicted frequency of unsuccessful outcomes is 50% with 76% displacement.

There continues to be great variation in the approach to treatment of displaced radial neck fractures in children. Suboptimal results occurred in 31% of the patients in this series, with worse results in patients older than ten years, who had increased fracture severity, and who underwent open reduction. Less invasive reduction methods should precede open reduction whenever possible.